Danielle Sackrider, LMSW Lindsay Bryan, LLMSW

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1 Wednesday, 12:30 2:00, E7 Michigan Child Collaborative Care (MC3): An Innovative Care Model to Increase Access to Mental Health Treatment for Children and Adolescents in Michigan Using Telephone Consultation and Telepsychiatry Danielle Sackrider, LMSW Objectives: Notes: Lindsay Bryan, LLMSW Identify advances in clinical assessment and management of selected healthcare issues related to persons with developmental disabilities 2. Discuss telephone consultation and telepsychiatry, steps for implementation and outcomes of those completed.

Michigan Child Collaborative Care (MC3): An Update on the Michigan Innovate Care Model to Increase Children and Adolescent Access to Mental Health Treatment Danielle Sackrider,

Psychiatry access program for primary care providers Just-in-time phone consultation Telepsychiatry evaluations Funded by: Medicaid Match Flinn Foundation Ravitz Foundation MC3

2 Michigan Child Collaborative Care (MC3): An Update on the Michigan Innovate Care Model to Increase Children and Adolescent Access to Mental Health Treatment Danielle Sackrider, LMSW Lindsay Bryan, LLMSW What is MC3? Psychiatry access program for primary care providers Just-in-time phone consultation Telepsychiatry evaluations Funded by: Medicaid Match Flinn Foundation Ravitz Foundation MC3 Goals Improve access to crucial mental health services for children, adolescents and high-risk women of childbearing age. Males to age 24, Females to 26 Encourage appropriate use of evidence-based pharmacotherapy. Increase primary care provider comfort, knowledge and ability in treating mental health problems. 1

VERMONT CHILD HEALTH IMPROVEMENT PROGRAM Why Primary Care Providers? Pediatricians prescribing 84.

3 Why Psychiatry Access Programs? Poor distribution of child and adolescent psychiatrists (Keller & Sarvet, 2013) MC3 delivers providers with psychiatry consultations regardless of accessibility in their area. VERMONT CHILD HEALTH IMPROVEMENT PROGRAM Why Primary Care Providers? Pediatricians prescribing 84.8% of psychotropic meds (Goodwin et al, 2001) 60-70% of PCPs report appointment delays for mental health referrals of 3-4 months (MCPAP Survey) 40% of visits in some primary care clinics main reason for the appointment (Keller and Sarvet, 2013) Less stigma in a PCP office than in mental health setting (Sarvet et. al, 2011; Mauksch et al. 2001) Patients and parents have comfort with their PCP (Sarvet et. al, 2011) Thomas and Holzer, JAACAP,

Current MC3 Counties Collaborators and Program Team UM Program Administration Sheila

Rich Dopp Maria Muzik Kate Fitzgerald Physician Champions Lia Gaggino Cynthia Smith

Lindsay Bryan Kathryn DeMaagd-Formanczyk Judy Parros Kalamazoo CMHSAS JffPtt Jeff Patton

Andrew Sahara Northern Lakes CMH Greg Paffhouse Mary Hubbard Who does MC3 Serve?

4 Current MC3 Counties Collaborators and Program Team UM Program Administration Sheila Marcus Jane Spinner Anne Kramer UM Consulting Psychiatrists Sheila Marcus Paresh Patel Rich Dopp Maria Muzik Kate Fitzgerald Physician Champions Lia Gaggino Cynthia Smith Cynthia Statler Liaison Coordinators Danielle Sackrider Greg Brainard/Susan Stendel Lindsay Bryan Kathryn DeMaagd-Formanczyk Judy Parros Kalamazoo CMHSAS JffPtt Jeff Patton Pat Weighman Diane Schaeffer North Country CMH Alexis Kazczinski Carole Merritt-Doherty Andrew Sahara Northern Lakes CMH Greg Paffhouse Mary Hubbard Who does MC3 Serve? Primary care providers who treat: Infants and children ages infancy through 26 High risk women during pregnancy and postpartum 3

PCP Enrollment Primary Care Provider signs agreement Creates online account to access: Pre-program surveys Educational Modules FAQ/Resource site Providers can utilize service same day agreement is

5 PCP Enrollment Primary Care Provider signs agreement Creates online account to access: Pre-program surveys Educational Modules FAQ/Resource site Providers can utilize service same day agreement is submitted How it works PCP enrolls in MC3 Program PCP identifies a patient for consultation Appropriate MC3 consultation service is utilized Evaluation of Program MC3 Consultation Process Information or resources provided to PCP or Family Liaison Coordinator Triages Call Crisis Intervention or Hospitalization Recommended Liaison Coordinator links Primary Care Provider to U of M Child/Adolescent Psychiatry for Telephone Consultation Telephone Consultation between Primary Care Provider and U of M Child/Adolescent Psychiatrist Liaison Coordinator documents care recommendations and provides necessary follow up. 4

Experience of Enrolled PCP Provider s Experience Effect of Program Challenges to PCP No to Poor Reimbursement Total number of consultations to date= 475 Regions: Hillsdale: 10 Northern: 11 Northern

6 Experience of Enrolled PCP Provider s Experience Effect of Program Challenges to PCP No to Poor Reimbursement Total number of consultations to date= 475 Regions: Hillsdale: 10 Northern: 11 Northern Lakes: 137 Southeast: 68 Western: 246 Missing: 3 Providers: Enrolled: 72 Not enrolled: 60 Total: 131 Reason for Consult: Services: 31 Meds: 401 Diagnosis: 54 Other: 22 Telephone Consultations: Age

7 300 Telephone Consultations: Gender Male Female Patient Data 2% currently seeing a psychiatrist 71% currently on psychotropic medications 97% had been on medications in the past 40% currently receiving therapy or other services 8% history of psychiatric hospitalizations 4% history of serious accidents or head traumas 5% PCP felt patient was at imminent risk for selfharm or harm to others 12% had a school-based plan such as an IEP or 504 *Based off 235 unique patients Provisional Diagnoses from Providers PCP Diagnosis Mood Disorders CAP Diagnosis 16.4% ADHD & Disruptive 19% 1.9% Bh Behavior Disorders 32.9% Anxiety Disorders 7.0% 20.9% 20.9% 26.6% 22.2% Pervasive Developmental Disorders Missing/Not Provided 23.4% 24.7% 6

Telepsychiatry Launched May 2013 A full psychiatry

telepsychiatry evaluation service Telepsychiatry Process

orientation LC to CAP briefing Presents CDI, MASC, RADS,

PCP recommendations Telepsychiatry Data 16 consultations

8 Telepsychiatry Launched May 2013 A full psychiatry evaluation done via videoconferencing Short wait for telepsychiatry evaluation service Telepsychiatry Process Prior phone consultation from PCP Patient/parent orientation LC to CAP briefing Presents CDI, MASC, RADS, TEEN-PHQ, VADPRS scores, patient history Evaluation CAP to PCP recommendations Telepsychiatry Data 16 consultations completed Patient s aged between 3 and 15 9 male, 7 female; 56.3% male, 43.7% female 7

9 Telepsychiatry Vignette Young boy with aggression, anger, and violence issues. PCP had 3 phone consultations prior to telepsychiatry. Provisional Dx was bipolar disorder, after consultation Dx Mood Disorder NOS Medications, diagnosis and therapy plan reviewed PCP reports frequency and intensity of patient s anger has significantly decreased since collaborating with MC3 Telepsychiatry Satisfaction Overall, how satisfied were you with the service provided today? Mostly or Very Satisfied 100% 80% Generally, how comfortable were you with the telepsychiatry service? How convenient is the location of your appointment today? 60% 40% 20% 0% Patient and Parent Telepsychiatry Satisfaction, Continued How would you rate the visual quality? How would you rate the sound quality? 100% 100% 80% 75% 60% 40% 20% Fair Good Excellent 50% 25% Excellent 0% Parent Patient 0% Parent and Patient 8

10 Telepsychiatry Satisfaction, Continued During the consultation today, how self-conscious did you feel because of the equipment? 70% 60% 50% 40% 30% 20% 10% 0% Parent Patient Slightly Not at all Would you be able to have a child psychiatry consultation without the availability of telepsychiatry? 60% 50% 40% 30% 20% 10% 0% Parent Definitely Not Probably Not Probably 70% 60% 50% How would you rate telepsychitary compared to face-to-face consultation? 40% 30% 20% Adequate Almost as Good As Good or Better 10% 0% -10% Parent Patient MC3 Program Evaluation Program Pre-survey Liaison Coordinator activity Patient demographics ER/hospitalization likely avoided Local availability of recommended services Increase in comfort/knowledge by enrolled providers FAQs Virtual group case consultation Education Modules Satisfaction survey results and feedback PCP Parent Patient 9

Other (School, Psych set-up, etc) Services Linkage

11 Liaison Coordinator Perspective Roles Responsibilities Perspective What do Liaison Coordinators do? 20% 3% 5% 1% 49% 21% Telephone Consultation Set up Other (School, Psych set-up, etc) Services Linkage Follow-up Information/Resources Data Pre-program Survey Practice Pattern Survey Health Opinion Survey 10

PCP Confidence in Accessing Resources Providers were Not at All Confident in accessing the following treatments: PCIT 61% Eating Disorder Treatment 53% DBT 52% Parent Management 48% Providers were

12 PCP Confidence in Accessing Resources Providers were Not at All Confident in accessing the following treatments: PCIT 61% Eating Disorder Treatment 53% DBT 52% Parent Management 48% Providers were Very Confident in accessing: CBT for Mood 19% CBT for Anxiety 14% Provider Satisfaction The procedures for obtaining a phone consultation were efficient and user friendly 99% Agree or Strongly Agree Fll Following the phone consultation ltti Iflt felt more confident that I could effectively treat this child s behavioral problems 98% Agree or Strongly Agree Phone Consultation Case 1 Vignette Young woman on an antidepressant became pregnant. PCP wanted help managing patient s depression in conjunction with her current medication and pregnancy. MC3 psychiatrist assisted provider in creating a plan to best care for the patient and her unborn child. 11

Case 1 Provider Feedback Provider strongly agreed with both of the following statements: The procedures for obtaining a phone consultation were efficient and user friendly.

13 Case 1 Provider Feedback Provider strongly agreed with both of the following statements: The procedures for obtaining a phone consultation were efficient and user friendly. Following the phone consultation I felt more confident that I could effectively treat this child s behavioral problems. Phone Consultation Case 2 Vignette 12-year-old boy on 6 psychotropic medications including: mood stabilizers, alpha-2-agonist, antidepressant, stimulant and a stimulant alternative. Provider recently started treating patient and reported being overwhelmed with the medications and didn t know where to start on treating the patient and removing what was believed to be too many medications. Case 2 Provider Feedback Reported relief that CAP concurred that medications were too many/too high. Felt supported in treating the patient and moving forward in reducing the pharmacological burden on the patient. Able to translate the MC3 consultation to other patient s in the provider s practice. 12

14 Additional Provider Feedback I greatly appreciate the opportunity to discuss patient management issues with an expert in child psychiatry. [Though] we discussed a specific case- our conversation will help me evaluate and manage many other patients. I hope this program will continue. It fills a huge void in patient care. I feel like I am able to translate conversations to other children I am seeing- thus not needing to call as often as I did in the beginning. Each time I speak with a doctor about the patient management I feel that I have learned something new and I feel more confident approaching the care. Growth and Status of MC3 Physician Champions Enrollment of Nurse practitioners Sh School-based lb settings Expansion Southeast Michigan North Country CMH catchment area Telepsychiatry growth and implementation What Have We Learned? If you build it they will come not the case Program evaluation requirements versus what is realistic i Program implementation across systems 13

15 Next Steps Program sustainability Examine blended models of collaborative care Embedded care implementation Geographic Expansion Continued Program Evaluation: Evidence-based psychopharmacology and therapy CAP Satisfaction Embedded Care Services provided in the PCP setting Type of Services Acceptance of Service by Patients Accessibility References A Guide to Building Collaborative Mental Health Care Partnerships in Pediatric Primary Care, AACAP, June, 2010 Goodwin, R., Gould, M. S., Blanco, C., & Olfson, M. (2001). Prescription of psychotropic medications to youths in office-based practice. Psychiatry Services, 52(8), Keller, D., & Sarvet, B. (2013). Is There a Psychiatrist in the House? Integrating Child Psychiatry Into the Pediatric Medical Home. Journal of the American Academy of Child and Adolescent Psychiatry, 52(1), 3-5. Mauksch, L. B., Tucker, S. M., Katon, W. J., Russo, J., Cameron, J., Walker, E., & Spitzer, R. (2001). Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. Journal of Family Practice, 50(1), Sarvet, B., Gold, J., & Straus, J. H. (2011). Bridging the divide between child psychiatry and primary care: the use of telephone consultation within a population-based collaborative system. Child and Adolescent Psychiatric Clinics of North America, 20(1), Thomas, C. R., & Holzer, C. E. (2006). The continuing shortage of child and adolescent psychiatrists. Journal of the American Academy of Child & Adolescent Psychiatry, 45(9),

16 Questions? 15

Children s Telephonic Psychiatric Consultation Service. Abigail Schlesinger, MD Medical Director, TIPS, Medical Director Integrated Care WPIC

Children s Telephonic Psychiatric Consultation Service Abigail Schlesinger, MD Medical Director, TIPS, Medical Director Integrated Care WPIC Outline Schedule/Goals for the day System of Care for Young